Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your starting dose of ponatinib for CML?
The standard starting dose for ponatinib is 45 mg. That being said, many clinicians lower the dose to 30 mg or 15 mg once a response is achieved in an effort to lower the rates of adverse events. The ongoing OPTIC study is evaluating if it is safe/effective to start at lower doses. An interim analys...
Do you have a preferred systemic therapy for unresectable epithelioid hemangioendothelioma?
Treat it like an angiosarcoma, albeit with a lower probability of response. Options include weekly Taxol or Gemzar/Taxotere or doxorubicin +/- Ifosfamide, depending on the gravity of the disease status.
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...
Which of the androgen blocking agents have the best CNS penetration for someone with metastatic CRPC with brain metastases?
There is no direct prospective clinical evidence to really answer this question, unfortunately. My approach to patients with CNS metastases (including epidural disease) from prostate cancer is to provide metastasis-directed therapy such as surgery or stereotactic radiation depending on a range of fa...
Would you consider giving FLOT entirely in the neoadjuvant setting for resectable gastric cancer?
I do favor trying to give all the chemotherapy upfront, including FLOT. This builds upon compelling data from other GI cancers, like rectal cancer and pancreas adenocarcinoma, and the evidence that there has never been a trial (to my knowledge) that showed worse outcomes with total upfront chemo, vs...
How would you approach timing of adjuvant chemotherapy in a Stage 1 TNBC lost to follow up for >1 month since surgery?
Delayed initiation of adjuvant chemotherapy beyond 60-90 days has been linked to inferior outcomes in several studies (see for example Chavez-MacGregor et al., PMID 26659132). However, if this worse outcome is primarily due to time delays in chemotherapy or driven by other variables (e.g. ability to...
Are you treating patients with RET-fusion+ metastatic NSCLC with RET inhibitors as the first line of therapy regardless of PD-L1 expression?
Yes, I do treat with RET inhibitors regardless of PD-L1 status given the response rates on the order of 70-85% in treatment naive patients with selpercatinib and pralsetinib. If we look to the data of immunotherapy in other actionable oncogene driven subsets of lung cancer like EGFR mt NSCLC, the re...
How would you treat patient with a recurrent thymic carcinoma after prior surgery and concurrent chemoradiation?
This is a bit difficult to answer as the background is a bit vague with uncertainty about the patient's primary therapy. In general, the approach I would take is that the curative approach is in the first-line setting, once there is a recurrence, it is typically incurable but they have a number of t...
How would you treat an older patient with stage IIC nonseminoma who is unfit for platinum chemotherapy due to comorbidities?
These are difficult questions to answer. The definition of a patient unsuitable for cisplatin in an elderly patient varies from oncologist to oncologist. Cisplatin + etoposide for 4 courses is the “standard“ therapy for patients over the age of 50. For elderly patients with poor performance status f...
How do you manage VTE in the setting of persistent severe thrombocytopenia?
The thrombosis versus bleeding risk ratio should be weighed. The risk of VTE recurrence or propagation is highest in the first 30 days and we know that thrombocytopenia does not attenuate this risk. Providers should favor anticoagulation. In the case of cancer-associated thrombosis and chemotherapy-...